Provider Demographics
NPI:1457477523
Name:GARY M TEARSTON MD A MEDICAL CORP
Entity type:Organization
Organization Name:GARY M TEARSTON MD A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:TEARSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-659-5502
Mailing Address - Street 1:PO BOX 18587
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90209-4587
Mailing Address - Country:US
Mailing Address - Phone:310-659-5502
Mailing Address - Fax:310-659-7639
Practice Address - Street 1:2122 CENTURY PARK LN
Practice Address - Street 2:UNIT 207
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-3304
Practice Address - Country:US
Practice Address - Phone:310-659-5502
Practice Address - Fax:310-659-7639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15838174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicare UPIN
CAG15838Medicare ID - Type Unspecified